There are many lessons to be learned from the serious case review of the Winterbourne View hospital scandal.

The need for improved monitoring of services by NHS commissioners has already been highlighted. But another big lesson is how we identifypeople who are at risk now or at most risk of finding themselves in the same or similar situation as the people with a learning disability found themselves in at Winterbourne View.

The Care Quality Commission has already started to take steps to address this but as Dame Jo Williams chair of the CQC honestly stated in her response on 7 August to the review, this "is not just a matter for CQC". The CQC cannot be expected to deal with this issue alone; it has neither the capacity nor the personal contact necessary.

Williams called this a "watershed" moment for the CQC, but I think it is a massive wake-up call for all of us involved in the social and health care sector.

The following first steps are vital for managers of public services to play their part in addressing this issue:

• Ensurepractitioners, care managers, social workers, health workers, reviewing teams etc, understand and demonstrate through their practice and behaviour that they really know what it means to truly listen to people who need support and to act on what they hear

• Listen to what people are saying is right for them; some people need the support of people around them to communicate, people that know and love them, ie their family members.

• Stop commissioners entering into contracts with organisations involved in setting up institutions and where these contracts exist, take steps now to discover a better way of supporting people in their communities.

Practioners will be outraged that people think they don't listen to their clients already. Our experience tells us that many believe they are listening – but the consequences of their actions tell another story.